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Section 24
Play Themes with Abused Children

Question 24 | Test | Table of Contents

Play Themes
Abused and neglected children have been observed displaying general themes of play that may be helpful in identifying and understanding the traumatized child (Chan & Leff, 1988; Terr, 1981). Unlike the play behaviors outlined earlier, these themes are recurrent patterns of interactions that surface over time. The two play themes identified are (a) unimaginative and literal play and (b) repetition and compulsion.

Unimaginative and Literal Play
Researchers have observed that the play of abused and neglected children is far less creative, imaginative, or elaborate than that of unabused children (Jacobson & Straker, 1982; Terr, 1981). Martin and Beezley (1977) have reported that these children lack "the capacity to play freely, to laugh and to enjoy themselves in an uninhibited fashion" (p. 374). They observed that 33 of the 50 physically abused children met the activities and games that children normally enjoy with sullenness, stoic acceptance, or opposition. Researchers have also observed that play fails to relieve anxiety for the abused child (Terr, 1981). Kempe and Kempe (1978) described abused children as moving from one toy to another in a haphazard, impulsive manner, unable to explore their environment comfortably or spontaneously. Unimaginative and literal play may be a reflection of the "parentified" and pseudo-adult life-style these children frequently develop to survive in chaotic and abusive homes (McFadden, 1986). It may also be a consequence of the generally more depressed affect found in abused children (Cohen & Mannarino, 1988). An example of unimaginative and literal play is the child who sweeps the floor, washes the play dishes and play clothes, carefully arranges stray toys, and then quietly waits for his or her parent to arrive.

Repetition and Compulsion
In her study of 12 children (ages 15 months to 12 years), Terr (1981) observed that those who have been physically or sexually traumatized may engage in a rigid set of play behaviors, repeatedly and unconsciously acting out the trauma they have experienced. This may continue until "they are told by parents or teachers to stop, until they are sent away, or until they reach an emotional understanding of the connection of their play to the original psychic trauma" (Terr, 1981, p. 745). This form of compulsive game playing evolves into one of the abused child's primary stress reduction mechanisms and usually appears as odd or out of place in the child's immediate environment. An example of a compulsive and repetitious play theme is the physically abused child who, each day upon entering the playroom, proceeds to check all doors and windows and shouts "Out! Out!" before playing with other toys or games (White & Allers, 1992). Two other examples of compulsive and repetitive play in sexually penetrated children are the following: the child who repeatedly rolls "worms" out of clay (Sikelianos, 1986) and the child who stuffs or forces toys into other toys (e.g., attempts to insert baby bottle between teddy's legs; McFadden, 1986). Repetitious and compulsive play was not identified as a characteristic theme in children experiencing only neglect.

Play Therapy Research Evaluation
Wyatt and Peters (1986) reviewed four representative studies of the child abuse research and found numerous methodological and theoretical problems in the study of traumatized children. In particular, they observed inadequacies and inconsistencies in the published researchers' definitions of abuse and neglect. Similarly, the authors of this study reviewed 22 published PT and childhood abuse and neglect articles. Along with identifying similar problems in the definition of abuse and neglect, the authors identified four additional research deficits. These deficits are inconsistent definitions of PT, inadequate definition of the qualifications and role of the play therapist, nonstandardization of PT materials and modalities, and inadequate or flawed statistical design.

Although clear and consistent definitions of abuse and neglect are starting to appear in the literature (Allers & Benjack, 1991; Burgess, 1985; Sgroi, 1982), of the 22 PT articles reviewed, only 4 provided a working definition of abuse and neglect. Unfortunately, these four definitions varied greatly. For instance, researchers such as Howard (1986) either created a specific definition for the area they were investigating or referred to preexisting, published definitions. Researchers such as Terr (1981) specifically described the abusive and neglectful circumstance(s). Others, such as Fagot et al. (1988) and TaylorMitchum (1987), failed to define childhood abuse and neglect in their reports. Until researchers in this area adopt and adhere to uniform and consistent definitions, research outcomes will continue to vary from investigation to investigation based on the individual researcher's experience with neglect and abuse.

Similarly, the definition of PT varied widely in the studies reviewed. Of the 22 studies examined, six primarily defined their work based on the fundamental PT guidelines of Axline (1947) or Landreth (1982). Five other researchers used the term play therapy but provided descriptions of work that represented more individual and unique therapeutic approaches to the use of play (e.g., Federation, 1986; Jernberg, 1979; McFadden, 1986). The remaining 11 studies failed to provide a specific definition of PT. The empirical validation of PT will require the consistent definition and application of play as a clinical treatment. Although therapists working from various theoretical orientations may have differing conceptualizations of the behavioral or emotive processes activated in play, the overall definition of PT must be consensually defined if research is to validate its utility as a therapeutic approach.

Another limitation of the PT and abuse and neglect research is the variability in the training of professionals using play in a clinical and research setting. Chan and Left (1988) stated, "(D)epending on the institutional organization, various caregivers, such as the child psychiatrist, child psychologist, pediatric social worker, and/or mental health nurse clinician, may use therapeutic play and/or play therapy" (p. 170). Although these health professionals may use play therapeutically, the mere use of play in and of itself is insufficient to qualify as PT. In reviewing the literature, we found four articles appropriately defining the role of a play therapist (e.g., In & McDermott, 1976; West, 1983) and five articles describing the general role of a helping professional who is using play therapeutically (e.g., Burch, 1980; Chan & Leff, 1988). The remaining articles did not describe the role of the professional so that we could evaluate the professional's training. Regardless of the clinician's theoretical orientation or background, the consistent training of therapists is essential to minimize the differential application of play in subsequent research. Consistent training, such as that suggested by Landreth (1991), would help to standardize research efforts and reduce outcome variability between studies.

Along with the variability in both definition and training, researchers have reported the use of nonstandard materials and modes in their study of abused and neglected children (Harper, 1991; Sinason, 1988). Although there may be a need for materials that are particularly sensitive to the issues and deficits of the traumatized child, research has failed to document which, if any, of the standard PT materials (Landreth, 1985) may be effective. Of those articles reviewed, only five listed all or most of the materials used in the research study (e.g., Nicol et al., 1988; West, 1983). The remaining articles either highlighted a few items or failed to mention any of the materials used. Similarly, variations in the use of different PT modalities (e.g., individual versus group, nondirected versus directed) create problems in the comparison and synthesis of research information (e.g., Fagot et al., 1989; Jernberg, 1979; TaylorMitchum, 1987). The standardization of PT materials and modes is essential if future research is expected to evaluate and extend the existing body of knowledge.

Most of the research on PT and childhood abuse and neglect has relied on nonstatistical observations using single cases or small-group samples (fewer than 12). In studies investigating larger groups, researchers failed to incorporate comparative control groups (Martin & Beezley, 1977; Nicol et al., 1988), suffered weak statistical power (Fagot et al., 1988), experienced low interrater reliability (Howard, 1986), or collected highly subjective data (Harper, 1991). Clearly, investigators must design research that encourages the collection of objective and relevant PT data and ensures the opportunity for powerful and descriptive statistical analysis.

Phillips (1985) summarized the observed research deficits most clearly. He stated, "What play therapy needs is a systematic program of research that clearly sets out its hypotheses, designs well controlled-studies, carefully selects subjects, measures meaningful outcome, and uses appropriate and informative statistics" (p. 758). Unfortunately, based on this review of the PT and childhood abuse and neglect research, there is little indication that Phillips's (1985) astute recommendations have made an impact.
- White, JoAnna, & Christopher Allers; Play Therapy with Abused Children: A Review of the Literature; Journal of Counseling & Development; Mar/Apr 1994, Vol. 72, Issue 4.

LIFE SKILLS SUPPORT GROUP CURRICULUM

- LIFE SKILLS SUPPORT GROUP CURRICULUM , CalWORKs Administration, County of Los Angeles Department of Mental Health, California Institute for Mental Health. Improving Mental Health Outcomes for CalWORKs Participants in Los Angeles County. Los Angeles, California: California Institute for Mental Health, 2007.

Personal Reflection Exercise #10
The preceding section contained information about play themes with abused children. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Play Therapy for Survivors of Sexual Abuse

- NA. (2022). Play Therapy for Survivors of Sexual Abuse. Family Strategies, 2022. https://family-strategy.com/play-therapy-sexual-abuse/

Peer-Reviewed Journal Article References:
Born, S. L., & Fenster, K. A. D. (2021). A case application of Adlerian play therapy with teachers to combat burnout and foster resilience. International Journal of Play Therapy.
Connolly, D. A., Coburn, P. I., & Chong, K. (2017). Twenty-six years prosecuting historic child sexual abuse cases: Has anything changed? Psychology, Public Policy, and Law, 23(2), 166–177.

Davis, E. S., Loeb, D., & Lee, T. (2021). Implementing play and language therapy to work with preschool children with language and behavioral issues. International Journal of Play Therapy, 30(2), 157–166.

Milner, J. S., & Crouch, J. L. (2012). Psychometric characteristics of translated versions of the Child Abuse Potential Inventory. Psychology of Violence, 2(3), 239–259.

Shevlin, M., Murphy, S., Elklit, A., Murphy, J., & Hyland, P. (2018). Typologies of child sexual abuse: An analysis of multiple abuse acts among a large sample of Danish treatment-seeking survivors of childhood sexual abuse. Psychological Trauma: Theory, Research, Practice, and Policy, 10(3), 263–269.

QUESTION 24
What two play themes does White identify with abused children? To select and enter your answer go to Test.